Healthcare Provider Details

I. General information

NPI: 1831024330
Provider Name (Legal Business Name): MATISON WILLIAM MCCOOL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9649 ASBURY LN NW
ALBUQUERQUE NM
87114-4344
US

IV. Provider business mailing address

4405 JAGER DR NE STE C4-4262
RIO RANCHO NM
87144-5709
US

V. Phone/Fax

Practice location:
  • Phone: 505-228-0142
  • Fax:
Mailing address:
  • Phone: 505-228-0142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-2025-0048
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: